Physician‐assisted dying in people with mental health conditions – whose choice?

Galderisi et al1 quite rightly draw our attention to the ethical dilemmas that emerge when one considers ending life. An area fraught with complexity takes a quantum leap when mental ill-health is added. The need to rethink a position is nothing new. Whilst we may perceive change as gradual, over a decade it may become seismic, and constant re-evaluation of values may be necessary. The ground-shaking judgment in Roe v. Wade case in the US, and its recent reversal, is one example of how what seems right and proper can change overnight. Even the most ardent supporters of choice would not support physician-assisted dying (PAD) in populations who lack decision-making capability, although some take the view that the Convention on the Rights of People with Disabilities (CRPD)2 would dispute that those with mental illness cannot make their own choices. Where is the boundary? Compromised is not impaired, let alone without value or meaning. In Japan, the Restaurant of Mistaken Orders employs staff with dementia, resulting in 37% of orders being mistaken, but 99% of customers report that they are happy3. The CRPD emphasizes multiple rights: the right to life (Article 10); to adequate standards of living and social protection (Article 28); to “legal capacity” – that is to legal standing as well as legal agency – on an equal basis with others” (Article 12); “…the existence of a disability shall in no case justify a deprivation of liberty” (Article 14); “…every person with disability has a right to respect for his or her physical and mental integrity on an equal basis with others” (Article 17). How do we reconcile these rights with the existence of PAD? Not a Pandora's box but a stack. One group states that those with mental illness must be allowed to participate equally. Yet, few psychiatrists would support that those with psychotic beliefs or severe depression should have access to PAD. How are these contrasting views, on conditions which may distort the ability to weigh up and evaluate choices, to be balanced? The WPA Code of Ethics calls for the autonomy of persons with mental ill-health, but recognizes that involuntary interventions may be required, as a last resort, when less restrictive interventions have failed, to protect safety and to restore the person's autonomy. PAD will never “restore” autonomy; it implements it for a last time! The line of reasoning that permits coercion is in the context of interventions that improve quality of life and return autonomy. There is no reasonable world in which PAD promotes these. For individuals who lack a formal mental disorder, but are facing the existential angst and distress of a terminal condition, or of unbearable suffering, the guiding principle shifts. The relief of suffering becomes more important. Autonomy takes priority when beneficence is unrealistic, and non-maleficence manifests as not making people suffer more than they choose to. Many clinicians will be familiar with the lack of parity between physical and mental health care, that the resource allocation is uneven and unequal, particularly galling when the World Health Organization identifies mental ill-health as one of the leading causes of disability-adjusted life years. Is it perverse that a call for parity means access to PAD on an equal basis? Another thread to concerns about PAD is: “How free is such a decision?”. There are concerns about societal pressures, not only involving human interactions. What is the influence of social media, and is that influence even human? Automated algorithms make a comprehensive and competent assessment of requests for PAD crucial. Given the finality of PAD, a cautious approach to criteria for consent is appropriate. Apart from the Netherlands and Belgium, countries which have an enshrined right to PAD do not extend that right to minors. One might consider that sensible for those with impaired capacity, whether developmental or pathological. That frameworks exist for the assessment of capacity does not take away from the need for staff to be properly trained. Despite teaching from national organizations, there is still widespread disparity in the quality of assessments, in this author's experience, even when workshops are delivered at meetings of the European Psychiatric Association or the American Psychiatric Association. Where death is the outcome, this is truly disturbing. I note that Galderisi et al allege that medical associations have moved to neutrality over time, “perhaps to spare members who participate in these now-legal interventions from being labelled as unethical”. In the UK, the movement of professional associations towards neutrality or being in favour of legalization, whilst lagging behind public opinion, precedes legislative change, suggesting that it is the reverse. Changing attitudes rather than avoiding regulatory proceedings seem to be the cause of the shift4. Another fear, that legalization and normalization of PAD will lead to a decline in palliative care for life-limiting conditions, is not borne out by an international evidence base5. Nor is it evident that PAD for psychological causes will open the floodgates, with only 5% of requests on this basis being approved6. As suffering is purely subjective, whether psychic or physical, disputes about its definition seem ironic. On the contrary, discussions about treatability are not subjective and can be evidence based. That only treatments which patients are willing to accept would be used in determining treatability is a challenge to autonomy, when set against societal values that life should be preserved. What is “untreatable” has been well analyzed before in this journal7, and the same arguments are as valid here. At the end of the day, disagreements about definitions do not invalidate the principle. It is the pragmatic that is questioned. Whilst the devil is in detail, it does not mean that the relief of irremediable unbearable suffering does not justify the legalization of PAD. It is a truly terrible decision, one that deserves compassion and empathy. When a process to leave this world is clearly articulated and lawful, evidence from EXIT (Switzerland) shows that, of those enquiring for PAD, 68% make a choice to live8. Societies have to make several hard decisions. When is capacity to exercise a choice for PAD present? What is “untreatable”? At what point is the burden of treatment such that more can be refused whilst retaining access to PAD? What would a compassionate caring process look like? In any case, vigilance to ensure that the principles are maintained, without deviation, will be required. In such a scenario, PAD has a place in civil society. A choice I hope you never need.